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Epidemiology of menthol cigarette use in theUnited StatesRalph S Caraballo1*, Katherine Asman2

Abstract

Background: Approximately one-fourth of all cigarettes sold in the United States have the descriptor “menthol” onthe cigarette pack. It is important to determine what socio-demographic factors are associated with smokingmenthol cigarettes if indeed these types of cigarettes are related to smoking initiation, higher exposure to smokeconstituents, nicotine dependence, or reduced smoking cessation.

Methods: The National Cancer Institute (NCI) conducted a review of the scientific literature on this topic which wecompleted by adding more recently published articles via PubMed. We also conducted further data analyses usingthe National Survey on Drug Use and Health, the National Youth Tobacco Survey, the Monitoring the FutureSurvey, and the National Health and Nutrition Examination Survey to provide up-to-date information on this topic.

Results: Menthol cigarettes are disproportionately smoked by adolescents, blacks/African Americans, adult females,those living in the Northeast of the United States and those with family incomes lower than $50,000. Based onself-reports of menthol cigarette use, menthol cigarette use among smokers have increased from 2004 to 2008.However, no increase was observed during these years for predominantly menthol brands like Newport™, Kool,™and Salem™, however, this lack of significant trend may be due, at least in part, due to smaller numbers ofsmokers of specific brands or sub-brands, which provide estimates which are less precise.

Conclusion: Menthol cigarettes are disproportionately smoked by groups of U.S. cigarette smokers. It is likely thatother disparities in menthol cigarette use exist that we have not covered or have not been studied yet.

BackgroundThere are over a thousand cigarette brands and sub-brands that are sold in the United States [1]. Cigarettebrands are advertised or described by some specificcharacteristics such as been filter or non-filter, by thelength of the cigarette, by its Federal Trade Commissionmachine-measured levels of tar, nicotine yield, and car-bon monoxide, and some brands of cigarettes have thedescriptor “menthol” in the pack [2].It has been proposed that the anesthetic and cooling

sensation properties of menthol allow smokers ofmenthol cigarettes (by menthol cigarettes we mean acigarette from a pack with the descriptor “menthol” init) to inhale more smoke from each cigarette than smo-kers of nonmenthol cigarettes (no “menthol” descriptor

in the cigarette pack) [3,4]. It has also been proposedthat smokers of menthol are more nicotine dependent,and as a consequence, are less likely to quit [5]. It hasbeen hypothesized that the resulting higher smoke expo-sure over time may result in higher smoking-related dis-eases among smokers of menthol cigarettes [5,6]. In theU.S., menthol brands tend to have higher yields of tar,nicotine, and CO, however, menthol is present atreduced levels in many nonmenthol brands [7]. Finally,it has been proposed that menthol levels in cigarettesmay play an important role in smoking initiation espe-cially among adolescents, most of whom are underage[8].In this article, we used a recent literature review by

The National Cancer Institute (NCI) to determine whatsocio-demographic factors are associated with smoking(e.g., initiation, cessation, exposure to smoke constitu-ents, nicotine dependence) menthol cigarettes and wecompleted it by adding more recently published articleswe identified via PubMed. We also conducted data

* Correspondence: [email protected] Stop K-50, Office on Smoking and Health, National Center for ChronicDisease Prevention and Health Promotion, Centers for Disease Control andPrevention, 4770 Buford Highway, N.E., Atlanta, GA, USAFull list of author information is available at the end of the article

Caraballo and Asman Tobacco Induced Diseases 2011, 9(Suppl 1):S1http://www.tobaccoinduceddiseases.com/content/9/S1/S1

© 2011 Caraballo and Asman; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

mailto:[email protected]

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analyses with several national data sets to provide up-to-date information on this topic.

MethodsBecause type of cigarettes smoked, including brand pre-ference, varies by age group [9,10], data on socio-demo-graphic factors associated with smoking mentholcigarettes will be presented separately for youth andadults. A review of the scientific literature on socio-demographic factors related to smoking menthol cigar-ettes was provided by the Department of Health andHuman Services’ National Cancer Institute (NCI) [11].For youth, there were nine articles listed in the biblio-graphy, of which one was conducted in Japan [12]. Ofthe eight studies conducted in the U.S., five [13-17] col-lected data using national samples, two were conductedin specific communities [18,19], and one study [20] wasqualitative (focus groups) in study design. Four of these8 U.S. articles presented data from cross-sectional stu-dies [13,14,17,18], two from a longitudinal study [15,16],and two from a convenience sample [19,20]. Becausemore recent information has been published or availablesince the NCI bibliography was provided, additional stu-dies or reports [8,10,21] are included in the youth sec-tion in this article. When appropriate, we report resultsfrom these studies in this review article.For adults, there were 15 articles listed and one letter

to the editor on the bibliography provided by NCI. Ele-ven of these 15 articles presented data from cross-sec-tional studies, four presented data from case-controlstudies or data were collected using convenience sam-ples. The most recent study listed [22] reported datacollected in 2002 from a specific U.S. population group(heroin users) in a specific location. Because of lack ofrecent data in the NCI bibliography, other studies andreports [8,10,23,24] were included in the adult sectionto provide more recent information on this topic. Alsowhen appropriate, we report results from these studiesin this review article.To provide up-to-date information on this topic, data

analyses were performed using specific data sets suchas the National Survey on Drug Use & Health[25],hence referred as NSDUH; the National YouthTobacco Survey[26], hence referred as NYTS; the Mon-itoring the Future Survey[27], hence referred as MTFS;and the National Health and Nutrition ExaminationSurvey[28], hence referred as NHANES. It is importantto note that the consistent collection of national dataon menthol cigarette use started fairly recently, in thelate 1990’s (MTFS) or in the early 2000’s (NSDUH,NYTS, and NHANES). Two-sided t tests were used toassess differences between population group percen-tages. For all tests, p<0.05 was considered statisticallysignificant.

NSDUHThe National Survey on Drug Use and Health (NSDUH)is a nationwide household survey that collects data ondrug use and drug abuse, including tobacco use, from arepresentative sample of the U.S. civilian, noninstitutio-nalized population aged 12 years or older. Specifically,the NSDUH collects data on overall tobacco use, cigar-ette smoking, and other behavioral information relatedto cigarette smoking and brand preference. NSDUHdata are collected through a computerized questionnaireadministered in the privacy of participants’ homes by aprofessional field interviewer who visits each selectedhousehold. Most responses are answered in private bythe participant, although the interviewer reads andenters the responses to some questions in the presenceof the participant. Questions about tobacco use wereadministered through audio, computer-assisted, self-interview methods to maximize privacy and improvereporting of sensitive behaviors. For our analysis usingthese data, we used information for adolescents aged12-17 years old who smoked in the past month(N=9,595) and adult smokers (aged 18 years or older)who smoked in the past month (N=62,010) from the 5surveys conducted in 2004, 2005, 2006, 2007, and 2008in order to determine prevalence of menthol cigaretteuse in the overall population of smokers as well as forspecific subgroups of smokers and to assess trends insmoking menthol cigarette use among smokers.

NYTSThe NYTS is a nationally representative sample of stu-dents enrolled in grades 6 through 12. The samplinguniverse consists of public and private school studentsin the 50 states and the District of Columbia. The sam-pling frame stratified the 50 states and the District ofColumbia by region and urbanicity. Primary samplingunits (PSUs), are selected with probability proportionalto the student enrollment in the PSU but giving dispro-portionate weight to Black, Asian, and Hispanicstudents.Schools are grouped by size as either large or small,

depending on whether they have at least 125 studentscombined in eligible grades. All students present in aselected classroom on the day of the interview areselected for the study. Schools or students who refusedto participate in the study are not replaced in thesample.Our analysis included 1,978 middle school students

and 6,163 high school students from year 2004, 2006,and 2009 combined who had valid information on theschool year, past 30 day smoking, brand use, andmenthol questions. Those who were excluded included:those who did not specify a grade in school or didn’tanswer the question (n=397); those who were not a


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current smoker or didn’t answer the question(n=67,809); those who said they didn’t smoke cigarettesduring the past 30 days, that they did not have a usualbrand when asked about brand use, or did not answerthe question (n=66,719); and those who said they do notsmoke cigarettes when asked about menthol cigarettesor did not answer the question (n=59,965).We analyzed data from 2,580 adolescent smokers

selected throughout 35 states (not all states are repre-sented because the survey design did not control forthis) and from 267 large and small private and publicschools.

MTFSThe Monitoring the Future Survey (MTFS) main datacollection involves a series of large, annual surveys ofnationally representative samples of public and privatesecondary school students in grades 8th, 10th, and 12th

throughout the coterminous United States. Staff mem-bers administer the questionnaires to students, usuallyin their classrooms during a regular class period. Partici-pation is voluntary. Parents are notified well in advanceof the survey administration and are provided theopportunity to decline their child’s participation. Ques-tionnaires are self-completed. For the combined years of1998 to 2008, there were 20,863 8th grade current smo-kers, 30,722 10th grade current smokers, and 40,914 12th

grade current smokers in our data analysis. We assessedtrends in smoking menthol cigarettes among adolescentsmokers.

NHANESThe National Health and Nutrition Examination Survey(NHANES) consists of a number of questionnairesadministered in the household followed by standardizedphysical examinations and additional tobacco use ques-tions administered in specially equipped mobile exami-nation centers (MECs). The NHANES target populationis the civilian, noninstitutionalized U.S. population. Thisnationally representative sample permits calculation ofnational estimates. NHANES over-samples low-incomepersons, adolescents 12–19 years, persons 60+ years ofage, blacks, and Mexican Americans. We used NHANESdata collected between January 2001 and December2006. The overall response rate to NHANES for 2003–2008 was 78%. The analytic sample for this studyincluded smokers aged 20 years and older who hadsmoked, who were recoded by NHANES as non-Hispa-nic white, non-Hispanic black/African American, orMexican American. Of the 14,272 white, black, or Mexi-can American adults aged 20 years and older who com-pleted the NHANES home interview. The final analyticsample included 2,319 individuals, of which 1,581

showed the 8 or 12 digit Universal Product Code (UPC)information on the side of the cigarette pack.

ResultsYouthIn the combined years 2004 to 2008, almost half of ado-lescent smokers aged 12 – 17 years reported smokingmenthol cigarettes [10], an estimated 1 million adoles-cents (Table 1). Self-reports of types of cigarettessmoked are subject to bias. This important topic will bediscussed in more detail later. Younger smokers aremore likely to smoke menthol cigarettes than oldersmokers [10,16]. Figure 1 shows that a higher propor-tion of cigarette smokers smoked menthol cigarettesamong adolescents (44.8%) than among young adultsaged 18-25 years (36.5%) or older adults (30.1%). Con-sistent with this result specifically for adolescent currentsmokers, data for years 2004, 2006, and 2009 in theNYTS survey shows that 49.4% of middle school currentsmokers and 44.9% of high school current smokersreported smoking menthol cigarettes (Table 2). Finally,Aplleyard and colleagues found in a school-based surveyusing 2000 NYTS data that 42.0% of high school smo-kers who smoked in the past 30 days reported to havesmoked a menthol brand [11].The proportion of menthol smokers among all cigar-

ette smokers is higher among adolescents than amongadults in most, but not all, racial or ethnic groups (Fig-ure 2). Among white, multi-racial, Asian, and Hispanicyouth, the proportions of adolescent cigarette smokersreporting smoking menthol cigarettes are significantlyhigher than among adults. However, the proportion ofAfrican American adolescent cigarette smokers (71.9%)reporting smoking menthol cigarettes is significantlylower than the corresponding proportion for AfricanAmerican adult smokers (82.7%). This observed differ-ence requires additional study to determine if it is a realdifference or an artifact of misreporting.Racial/ethnic groupBig racial/ethnic differences exist in menthol cigaretteuse. Very high proportions of black/African Americanadolescent smokers smoke menthol cigarettes[13,25-27]. Recent national data shows that about sevenof ten African American smokers in this age groupreported smoking menthol cigarettes, followed by aboutmore than half of multi-race and Asian adolescent smo-kers (Figure 2). Data from the NSDUH survey showsthat among adolescent smokers aged 12-17 years, 51.5%of Asians, 47.0% of Hispanics, and 41.4% of NativeHawaiians/Pacific Islanders reported smoking a mentholbrand in the past 30 days. Similarly, a study conductedby Appleyard [13] and colleagues using 2000 NYTS datashowed that 58.0% of Asians reported using a menthol


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cigarette brand. However, in another study conductedby Moolchan [19] in Baltimore, MD he found no differ-ence in menthol cigarette use between blacks/AfricanAmericans (99.3% and 97.6% for males and females,respectively) and whites (92.3% and 87.5%, respectively).This study, however, used a convenience sample.

Appleyard and colleagues also found that high schoolblack/African American, Asian, and Native Hawaiianand Pacific Islander smokers were more likely to reportsmoking menthol cigarettes than their counterparts inmiddle school; while white and Hispanic high schoolsmokers were less likely to report smoking mentholcigarettes than their counterparts in middle school [13].A similar finding for whites and Hispanics (less smokingof menthol cigarettes among high school students) wasfound by Hersey and colleagues [14].GenderNo consistent gender difference in menthol cigarette useis observed among adolescents. The scientific literatureprovided found no gender difference in menthol cigar-ette use between male and female adolescent smokers.Giovino [9], Hersey [14], Kaufman [15], Cummings [18],Johnston [21] found no gender difference between malesand females who smoked the menthol brand Newpor-t™*or reported smoking menthol cigarettes in general.The use of trade names is for informational purposesonly and in no way implies endorsement by the USGovernment, the US Department of Health and Human

Table 1 Prevalence for menthol by gender and age, NSDUH 2004-2008, by Year

YR Age GENDER Menthol RowPercent

Lower 95% LimitROWPER

Upper 95% LimitROWPER

SampleSize

WeightedSize

2004 12-17 Male MentholCigarettes

40.35 36.44 44.39 410 560703

Non-menthol cigs 59.65 55.61 63.56 609 828727

Female MentholCigarettes

46.26 42.07 50.5 530 665927

Non-menthol cigs 53.74 49.5 57.93 605 773719


37.09 32.82 41.59 382 485098

Non-menthol cigs 62.91 58.41 67.18 633 822642


46.14 41.55 50.8 490 586310

Non-menthol cigs 53.86 49.2 58.45 593 684353


40.41 35.38 45.65 379 505145

Non-menthol cigs 59.59 54.35 64.62 569 744819


47.05 43.17 50.97 420 603299

Non-menthol cigs 52.95 49.03 56.83 506 678935


46.93 42.96 50.93 460 586303

Non-menthol cigs 53.07 49.07 57.04 511 663058


50.24 46.52 53.97 416 560236

Non-menthol cigs 49.76 46.03 53.48 415 554793


48.35 43.88 52.84 383 510494

Non-menthol cigs 51.65 47.16 56.12 467 545410


48.2 43.86 52.57 398 496226

Non-menthol cigs 51.8 47.43 56.14 419 533267

Source: U.S. Department of Health and Human Services. The NSDUH Report: Use of Menthol Cigarettes. Results from the 2008 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 09-4434, NSDUH Series H-36). Also available online: http://oas.samhsa.gov.

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12-17 18-25 26+

Figure 1


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Services, or the US Centers for Disease Control and Pre-vention. Additional analyses were performed using datafrom the NSDUH, NYTS, and MTFS. NSDUH datashowed that girls aged 12-17 years were more likely tosmoke menthol cigarettes than boys the same age inyears 2004, 2005, and 2006, but no gender differencewas observed in 2007 and 2008 (Table 1). When genderdifference for this age group was assessed looking at the

youth menthol leading cigarette brand Newport™, nodifferences were observed in any of these years (data notshown). Using NYTS data for years 2004, 2006, and2009 combined, no gender difference in menthol cigar-ette use was observed in middle school (47.9% forfemales, 50.9% for males), however, a gender differencewas observed in high school students, with femalesmore likely to smoke menthol cigarettes than males

Table 2 Gender differences for menthol use, NYTS 2004, 2006, 2009

YR School Gender Menthol RowPercent



SampleSize

WeightedSize

p-Value

2004 MiddleSchool

Female All 100 . . 554 470,743 0.5465

Menthol 49.3 44.19 54.43 282 232,081

Non-menthol 50.7 45.57 55.81 272 238,661

Male All 100 . . 517 409,789

Menthol 47.94 44 51.9 262 196,437

Non-menthol 52.06 48.1 56 255 213,352

HighSchool

Female All 100 . . 1214 1,459,070 0.001

Menthol 49.38 42.06 56.73 614 720,532

Non-menthol 50.62 43.27 57.94 600 738,538

Male All 100 . . 1290 1,360,050

Menthol 39.14 34.02 44.51 552 532,345

Non-menthol 60.86 55.49 65.98 738 827,705

2006 MiddleSchool

Female All 100 . . 350 363,257 0.0732

Menthol 42.54 36.73 48.57 157 154,529

Non-menthol 57.46 51.43 63.27 193 208,727

Male All 100 . . 367 329,602

Menthol 50.11 45.31 54.91 187 165,174

Non-menthol 49.89 45.09 54.69 180 164,427

HighSchool

Female All 100 . . 1102 1,275,510 0.0066

Menthol 44.82 37.05 52.86 541 571,688

Non-menthol 55.18 47.14 62.95 561 703,822

Male All 100 . . 1304 1,367,304

Menthol 37.8 32.74 43.14 544 516,841

Non-menthol 62.2 56.86 67.26 760 850,463

2009 MiddleSchool

Female All 100 . . 232 245,933 0.5966

Menthol 52.97 47.07 58.79 121 130,275

Non-menthol 47.03 41.21 52.93 111 115,658

Male All 100 . . 277 327,945

Menthol 55.37 45.71 64.63 142 181,569

Non-menthol 44.63 35.37 54.29 135 146,376

HighSchool

Female All 100 . . 935 1,070,338 0.0001

Menthol 54.28 47.71 60.69 508 580,941

Non-menthol 45.72 39.31 52.29 427 489,396

Male All 100 . . 1188 1,433,809

Menthol 45.78 41.53 50.09 574 656,388

Non-menthol 54.22 49.91 58.47 614 777,421


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(p-value= 0.0001) (Table 2). When data for all 3 yearswere combined, 49.2% of high school girls reportedsmoking menthol cigarettes compared to 41.0% of highschool boys (results not shown). However, no differ-ences were observed in using Newport™ between malesand females when using 2004, 2006, and 2009 combinedNYTS data (results not shown). MTFS for years 2004-2009 found no gender difference in smoking Newport™among 8th, 10th, or 12th graders (data not shown).Brand preferencesResearch has shown that cigarette brand use varies by age,gender, and race/ethnicity [23,24,29,30]. Since efforts wereinitiated in specific studies in the late 1980’s [15,16] andthe early 1990’s [18] to assess cigarette brand preferenceamong adolescent smokers, Marlboro™, Newport™, andCamel™ were the top three cigarette brands smoked byadolescent smokers. Kaufman and colleagues [15] statedthat even though market shares for the cigarette brandsMarlboro™ and Camel ™changed little between 1989 and1996, the prevalence of smoking Newport™ cigarettesdoubled among white and Hispanic adolescents whousually bought their cigarettes during that period. Barkerand colleagues [16] also found that the prevalence ofsmoking Newport™ cigarettes increased among adoles-cents from 1989 to 1993, and also for Camel™, while theprevalence of smoking Marlboro™ cigarettes decreasedduring this period. Consistent with results from earlieryears, the 1999 MTFS report [21] showed that Marlboro™was the predominant brand for 8th, 10th, and 12th graders,ranging from 53.7%, 61.1%, to 65.2%; followed by thementhol brand Newport™ (22.5%, 17.7%, and 13.3%,respectively). The third-ranked brand was Camel™ (5.4%,7.3%, and 9.6%, respectively). Also consistent with earlierstudies [15,18] big racial/ethnic differences were found.While the great majority of white (61-70%) and Hispanic(57-65%) smokers smoked Marlboro™, the vast majorityof blacks/African Americans smoked Newport™ (71-82%). Similar results were observed by Appleyard and

colleagues [13] using 2000 NYTS data for middle and highschool students. Appleyard found that the vast majority ofwhite, Hispanic, Asian, and Native Hawaiian/Pacific Islan-der adolescent smokers smoked Marlboro™, and the vastmajority of black/African American adolescent smokerssmoked Newport™. The predominance of these threecigarette brands still persist [24]. Figures 3 to 5 using 1998to 2008 MTFS surveys show that the three leading cigar-ette brands smoked by adolescents are Marlboro™, New-port™, and Camel™, in that order. A 2005 NSDUHreport on cigarette brand preference showed that 81.3% ofsmokers aged 12-17 years and 82.4% of smokers aged 18to 25 years smoked one of the top 3 brands [24]. Those 26years or older reported to smoke a somewhat more diver-sified selection of cigarette brands, only 54.1% of smokerssmoked one of the top 3 brands.Geographic Differences in Cigarette Brand Use PreferencesData on use of menthol cigarettes by region they live inthe U.S. is scarce. Compared to the East region of theUnited States, Kaufman and colleagues [15] found in the1990’s that adolescents living in the Midwest, South,and West were less likely to smoke Newport™ andmore likely to smoke Marlboro™.Smoking initiationIt has been hypothesized that menthol cigarette brandsplay an important role in smoking initiation. Whenlooking at three age groups (12-17 years, 18-25 years, 26years or older), the younger the age group, the morelikely it is to report smoking menthol cigarettes [10].Unfortunately, data on this topic is scarce and data fromcohort studies are lacking. It is important to clarify thatthe age of a smoker and smoking initiation is notequivalent. A person that is younger may have beensmoking longer than an older person. For example, anadolescent aged 14 years may have been smoking for 3years, while a young adult aged 19 years may havestarted smoking less than 1 year ago. Thus, age or agegroup (12-17 years, 18-25 years, 26 years or older) ofthe smoker is not equivalent to smoking initiation. The

Source: National Survey on Drug Use and Health, 2004-2008. http://www.oas.samhsa.gov/nhsda.htm

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12 - 17 years18+ years

AfricanAmerican

NativeHawaiian/

PacificIslander

Multi-racial Asian Hispanic AmericanIndian/Alaska

Native

White

Figure 2

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008Years

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Source: Monitoring the Future Surveys, 1998-2008 http://monitoringthefuture.org

Camel Kool Salem

Marlboro Newport

Figure 3


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best study design to assess if adolescents and youngadults are starting to smoke with a menthol cigarettebrand is a prospective/cohort study. However, no cohortstudy we are aware of collects this type of informationfor persons younger than age 18 years, when mostsmoking initiation happens.Due to lack of information on smoking initiation with

menthol cigarettes from prospective studies, and in anattempt to determine if smoking initiation is correlatedwith menthol cigarette use, we conducted an analysisusing cross-sectional data to determine the prevalenceof self-reported menthol cigarette use at different“stages” or trajectories of cigarette smoking among ado-lescents in grades 6th – 12.th This type of analysis hasbeen used to determine the prevalence of nicotinedependence at different stages/trajectories of cigarettesmoking among adolescents [31]. Although thisapproach is inferior to collecting data from prospectivestudies, it is also true that patterns of cigarette smokingdevelop over months or years within individuals. In fact,most new smokers take an average of 2-3 years fromthe time they smoked their first cigarette to the timethey become daily smokers [32]. Thus, the analysis pre-sented here for respondents who started smoking less

than 2 years ago may give us an insight on the relationof smoking initiation (earliest stages/trajectories ofsmoking) and the use of menthol cigarettes. We com-bined data from the 2004, 2006, and 2009 NationalYouth Tobacco Survey (NYTS). When looking at poten-tial “stages” or trajectories of cigarette smoking and theuse of menthol cigarettes, no significant differences wereobserved between “stages” or trajectories and the preva-lence of smoking menthol cigarettes (Table 3). Amongadolescents who smoked <1 cigarette per day (CPD) on1-5 days of the past 30 days, 39.9 percent reportedsmoking menthol cigarettes. For those who smoked 1-5CPD on 1-5 days, 6-9 days, 10-19 days, 20-29 days, andall 30 days, the self-reported prevalence of smokingmenthol cigarettes among all smokers was 45.3%, 47.5%,44.2%, 49.7%, and 46.6%, respectively. Among thosesmoking all 30 days, 42.7% of those who smoked 6-10CPD, 43.3% of those who reported smoking 11-20 CPD,and 64.9% of those who smoked 20 or more CPD saidthey smoked a menthol brand. Thus, if smoking amenthol cigarette is a factor associated with smokinginitiation, it would be expected to see a higher propor-tion of menthol cigarette smokers at the earlier stages/trajectories of cigarette smoking. In fact, we found theprevalence of menthol use to be lower among thosewho smoked <1 CPD on 1-5 days than those whosmoked 1-5 CPD on 1-5 days or 1-5 CPD on 20-29 daysand to be similar to those in other stages/trajectories ofcigarette smoking. Also, those at the highest level ofcigarette smoking (20+ CPD on all 30 days) were morelikely to report smoking menthol cigarettes than allother smoking stages/trajectories. Thus, we found noindication that adolescent smokers are more likely toinitiate smoking by smoking menthol cigarettes.Trends in menthol cigarette useIn general, the prevalence of cigarette smoking in the U.S. has been declining for adolescents over the past 10years. The Youth Risk Behavior Survey (YRBS) showsthat cigarette smoking among 9th-12th grade studentsfell by 44% from 1997 to 2007, from 36.4% to 20.0%, apercentage point decline in smoking prevalence of 16%[32], while the proportion of adolescent cigarette smo-kers reporting to smoke menthol cigarettes hasincreased significantly from 2004 to 2008 (Figure 6).Among all past-month smokers aged 12-17 years, theproportion of smokers reporting smoking mentholcigarettes increased significantly from 43.4% in 2004 to48.3% in 2008, for an 11% increase over 4 years. Thisincrease in the proportion of adolescent cigarette smo-kers who smoked menthol cigarettes reflects an increasein menthol cigarette use among white adolescents(40.3% to 46.0%), who were the only racial/ethnic groupto show a significant increase over this period (resultsnot shown). Looking at trends of some specific cigarette

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008Years

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Source: Monitoring the Future Surveys, 1998-2008. http://monitoringthefuture.org

Camel Kool Salem

Marlboro Newport

Figure 4

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50

60

70

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008Years

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ent

Source: Monitoring the Future Survey, 1998-2008. http://monitoringthefuture.org

Camel Kool Salem

Marlboro Newport

Figure 5


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brands using MTFS data from 1998 to 2008, no consis-tent or significant change was observed during this per-iod for Newport™, a predominantly menthol brand,among 8th, 10th, and 12th graders, however, a significantincrease was observed for Kool™, another mentholbrand, for 10th and 12th graders (Figures 3, 4, 5).

Similarly, using data from the 2004, 2006, and 2009NYTS survey, a slight nonsignificant decrease in smok-ing Newport™ was observed among middle school smo-kers and no change among high school smokers (Figures7 and 8). The lack of significant changes for specificcigarette brands over time may be due, at least in part,to less precision of the estimates due to smaller samplesize numbers.

Table 3 Percentage of respondents who reported smoking menthol cigarettes by quantity and frequency of pastmonth cigarette use (2004, 2006, and 2009 combined NYTS).

Days smokedP30D

Cigday Menthol RowPercent



SampleSize

WeightedSize

1-5 days < 1 CPD Menthol 39.92 37.41 42.48 794 245,029

Non-menthol

60.08 57.52 62.59 1109 368,755

1-5 CPD Menthol 45.32 42.73 47.94 999 333,274

Non-menthol

54.68 52.06 57.27 1145 402,075

6-9 days 1-5 CPD Menthol 47.47 41.73 53.27 334 111,694

Non-menthol

52.53 46.73 58.27 353 123,604

10-19 days 1-5 CPD Menthol 44.2 38.81 49.74 419 140,144

Non-menthol

55.8 50.26 61.19 466 176,911

20-29 days 1-5 CPD Menthol 49.69 44.12 55.26 387 150,554

Non-menthol

50.31 44.74 55.88 370 152,443

30 days 1-5 CPD Menthol 46.57 40.59 52.65 396 139,479

Non-menthol

53.43 47.35 59.41 375 160,050

6-10 CPD Menthol 42.72 36.42 49.27 323 118,387

Non-menthol

57.28 50.73 63.58 344 158,725

11-20CPD

Menthol 43.33 36.06 50.9 196 80,015

Non-menthol

56.67 49.1 63.94 209 104,659

20+ CPD Menthol 64.87 59.38 70 283 94,965

Non-menthol

35.13 30 40.62 136 51,424

Source: National Surveys on Drug Use & Health, 2004-2008. http://www.oas.samhsa.gov/nhsda.htm

0102030405060708090

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Figure 6

Source: National Youth Tobacco Surveys, 2004, 2006, and 2009. http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/

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Figure 7


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Camel™ and Marlboro™ cigarette brands come bothin menthol and nonmenthol. The MTFS survey doesnot distinguish however between these two types ofcigarettes. The MTFS data from 1998 to 2008 showed asignificant increase in Camel™ use for boys and girls in10th and 12th grade and declines in Marlboro™ useamong smokers in 8th, 10th, and 12th grade (Figures 3 to5). A decline in Marlboro™ use was also observedamong middle and high school boys and girls in the2009 NYTS compared to previous years (data notshown). However, because most of the cigarette marketshare is driven by adult smokers, this decline may notbe reflected in the overall Marlboro™ market share.Finally, Kreslake and colleagues reported that expendi-tures in advertising for nonmenthol brands declinedfrom $309.3 million in 1998 to $39.8 million in 2005while expenditures in advertising for menthol brandsincreased from $36.5 million to $43.8 million duringthat period [8]. It is known that adolescents are highlysusceptible to advertising influences. Tobacco advertis-ing, marketing, and promotion play an important role inincreasing smoking initiation and tobacco use amongyouth [34]. Youth have been purposely targeted throughadvertising, marketing, and promotion [34]. The totalweight of evidence presented by the 2008 NCI’s Mono-graph #19, which was assessed from multiple studytypes including experimental, cross-sectional, and longi-tudinal studies, and conducted by investigators from dif-ferent disciplines using data from several countries,demonstrated a causal relationship between tobaccoadvertising, marketing, and promotion that ultimatelyincreased smoking initiation and tobacco use [34]. It ispossible that increases in expenditures in advertising formenthol brands resulted in increases in youth exposureto such advertising, which then resulted in increase pre-valence of use of menthol cigarette brands.

AdultsAbout three out of ten adult cigarette smokers reportedsmoking a menthol cigarette brand (Figure 1). Young

adult smokers aged 18-25 years are more likely tosmoke menthol cigarettes than older adult smokers(aged 26 years or older). Figure 1 shows that a higherproportion of cigarette smokers aged 18-25 yearssmoked menthol cigarettes (36.5%) than older adults(30.1%).Racial/ethnic groupAmong adult smokers, the vast majority of black/AfricanAmerican adults reported smoking a menthol cigarettebrand [18,22,35-39]. Other ethnic groups that may havea high proportion of menthol cigarette smokers arePuerto Ricans [37], Asians [39], and Native Hawaiians/Other Pacific Islanders (Figure 2). More recent informa-tion using data from the NSDUH survey shows thatabout eight of ten black/African American adult smo-kers reported smoking menthol cigarettes, followed byabout half of Native Hawaiian and Other Pacific Islandadult smokers (Figure 2). In fact, almost half of adultmenthol cigarette smokers are from minority racial/eth-nic groups. Analyses with this NHANES data confirmthe NSDUH result that most black/African Americansmokers smoke a menthol brand (results not shown).Thus, one consistent finding is that black/African Amer-ican smokers are far more likely to smoke a mentholcigarette brand than smokers of other U.S. racial/ethnicgroups, however, some other racial/ethnic groups ofsmokers such as Hawaiians and Other Pacific Islandersand probably Puerto Ricans also smoke menthol cigar-ettes in high proportion [37,39].GenderSeveral studies [18,22,35-39] and further data analysesperformed using recent NSDUH (2004-2008) andNHANES (2003-2008) data confirm that female adultsmokers are more likely to smoke menthol cigarettesthan male adult smokers (Table 4). The scientific litera-ture is consistent in this finding for adult smokers butnot for adolescent smokers. NSDUH (2004-2008) datashows that a higher proportion of adult female smokersthan adult male smokers reported smoking mentholcigarettes. This was observed for both 18-25 years and26 years or older. The gender difference was alsoobserved among African Americans, whites, and Hispa-nics (Figure 9). The lack of a significant gender differ-ence for the other racial/ethnic groups probably resultedfrom the lack of precision of the estimates for thesepopulations due to small sample size. However, no gen-der difference was observed for the menthol brand New-port™ when using 2004-2008 NSDUH data (data notshown). Further analysis using NHANES 2003-2008data in which smokers showed their pack of cigarettesto the interviewer also showed a gender differencewhere female adult smokers aged 26 years or older weremore likely to smoke a menthol brand than their malecounterpart, but not so among the age group 20-25

Source: National Youth Tobacco Surveys, 2004, 2006, and 2009. http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/

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Figure 8


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years old, probably due to smaller sample size numberof smokers in the survey in this age group (results notshown). No gender difference in Newport™ use wasobserved between males and females in the age groups20-25 years or 26 years or older in NHANES (resultsnot shown).Brand preferencesWe mentioned earlier that cigarette brand use varies byage and that cigarette brands selection is more diversi-fied for adults aged 26 years or older than those aged12-17 years and 18-25 years old. The 2005 NSDUHreport showed that 54.1% of smokers’ aged 26 years orolder smoked one of the top 3 brands (Marlboro™,Newport™, Camel™) compared to 81.3% of smokersaged 12-17 years and 82.4% of smokers aged 18 to 25years (24). Table 5 and Figure 10 show the distributionof specific menthol and nonmenthol brand use by smo-kers aged 20 years or older verified by the UPC code.The percent of menthol smokers among all smokers for2003-2008 was 27.4%. This is similar to reported marketshare data for years 2003-2005 [1], where mentholbrands represented about 26% to 27% of the marketshare of cigarettes; except for 2006, when it wasreported to be 20%. Both Table 5 and Figure show that

among specific menthol brands, Newport™ is the lead-ing menthol brand smoked by adult smokers (7.8% -11.6%), followed by Marlboro Menthol™ (3.9% - 5.9%),Kool ™ (2.4% - 3.2%), and Salem™ (1.2% - 3.2%).When menthol brands other than the ones mentionedabove were combined, they represented about 7.0% -8.7% of the brands smoked by all adult smokers. Marl-boro™ nonmenthol brands (33.3% - 39.8%) and non-menthol brands (27.2% - 33.0%) other than Camel™represented the vast majority of brands smoked by adultsmokers.Geographic differences in cigarette brand useData on use of menthol cigarettes by region they live inthe U.S. is also scarce for adults. A table using 2000NSDUH data showed that smokers living in the North-east of the United States were more likely to reportsmoking menthol cigarettes [9] than those living in theSouth, North Central, and West of the United States.Similarly, a 2005 NSDUH report on brand preferencesconfirmed that 18.2% of smokers aged 12 years or older,the vast majority of them adult smokers, and living inthe Northeast reported smoking Newport™ comparedto 10.7%, 12.4%, and 3.3% in the Midwest, South, andWest of the United States, respectively [24].IncomeData on income and the use of menthol cigarettes isalmost nonexistent in the scientific literature. A dataanalysis using 2004-2008 NSDUH showed that adultsmokers with family incomes of less than $50,000 weremore likely to smoke menthol cigarettes than adultsmokers with higher family incomes (Figure 11).Trends in menthol cigarette useFrom 2004 to 2008, the proportion of menthol cigarettesmokers among all cigarette smokers increased amongadults aged 18-25 years and 26 years or older (Figure 6).The proportion of cigarette smokers who reportedsmoking menthol cigarettes increased significantly from2004 to 2008 among white and Hispanic men (Figure12). No changes were observed for white, black/AfricanAmerican, and Hispanic women (results not shown).The lack of significant changes for black African

Table 4 Proportion of current smokers who use menthol cigarettes by gender and age, NHANES 2003-2008, combined

AGEGRP Gender Menthol Row Percent Lower 95% Limit ROWPER Upper 95% Limit ROWPER Sample Size Weighted Size

20-25 Male Menthol 28.07 19.84 38.10 56 784,882

Non-Menthol 71.93 61.90 80.16 100 2,011,301

Female Menthol 34.4* 24.12 46.38 47 644,391

Non-Menthol 65.6 53.62 75.88 70 1,228,981

26+ Male Menthol 20.05 16.95 23.56 303 3,212,510

Non-Menthol 79.95 76.44 83.05 854 12,806,029

Female Menthol 35.06 30.97 39.38 363 5,166,768

Non-Menthol 64.94 60.62 69.03 568 9,569,979

* Estimate may be unreliable due to small sample size (less than 50 participants in cell).

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American men and women may be explained, at least inpart, to a ceiling effect, where about 80% of men and90% of women who smoked already smoked a mentholbrand. Looking at trends in cigarette brand use from2002 to 2008 using NSDUH data, no significant changesof Marlboro™, Newport™, or Camel™ use wereobserved for young adults aged 18-25 years (Figure 13),nor for smokers aged 26 years or older (Figure 14). Thelack of significant changes for specific cigarette brandsover time may be due, at least in part, to less precisionof the estimates due to smaller sample size numbers.Kreslake and colleagues reported an increase for Marl-boro Menthol™ sales data [8]. They found that althoughcigarette sales in the U.S. declined 22% from 2000 to2005, that the sales of menthol cigarettes remainedstable and that Marlboro Menthol™ had a consistentmarket share growth that started in the early 1990’s upto 2006, most recent data available when they publishedtheir article. In 2006, the authors reported, Newport™was the leading menthol brand, followed by MarlboroMenthol™, which they stated was particularly popularamong young adult smokers. Using 2004-2008 NSDUHdata, we found that for adult smokers, even though theprevalence of cigarette smoking remained the same in2008 (20.6%) compared to 2004 (20.9%), the self-reported use of menthol cigarettes increased during

those years for adults, more so for those aged 18-25years than those aged 26 years or older.Menthol cigarette use self-report biasAs previously stated, self-reports of types of cigarettessmoked are subject to bias. For example, Hersey [14],Giovino and colleagues [9] as well as Kreslake and col-leagues [8] found that menthol cigarette use self-reportsare subject to misclassification, probably more so oncertain subgroups such as adolescents. Kreslake and col-leagues found that 83% of adolescents aged 12-17 yearswho smoked Newport™, a menthol brand, also reportedthey were smokers of menthol cigarettes when asked ina separate question, thus 17% of them reported to besmokers of nonmenthol cigarettes which is inconsistentwith the menthol brand Newport. When a similarassessment was made for participants aged 35 years orolder, they found that only 5% of Newport™ smokersreported in a separate question to be smokers of a non-menthol brand [8].Compared to most adult smokers, most adolescent

smokers can be considered to be novice smokers. Thefact that a substantial proportion of current (smoking atleast 1 day of past 30 days, even a puff) adolescent smo-kers (e.g., first triers, experimenters, <weekly smokers)will not be considered to be an established adult smoker(100 cigarettes smoked or more in lifetime) is likelyrelated to the differential misreporting of the use ofmenthol cigarettes between the two age groups. Forexample, a paper published recently by Caraballo andcolleagues [31] shows that 26.8% of current adolescentsmokers aged 12-18 years started smoking <1 year priorto the time of the interview. In contrast, the vast major-ity of adult smokers are established smokers, smokeevery day (80%), buy their own cigarettes, and most ofthem smoke at least half-a-pack a day. Learning specificbrand characteristics (e.g., full flavor, light or ultra-light;Marlboro Mild™, Marlboro Menthol™, Newport; ™menthol or nonmenthol) develops over time. It is likelythat many adolescent smokers are less knowledgeablethan adult smokers of the specific characteristics of thecigarettes they smoke, especially those who are early in

Table 5 Menthol brand use assessed with UPC bar code among adult smokers aged 20 years or older, NHANES 2003-2008.

5 Common Brand + Menthol info Column Percent Lower 95% Limit ROWPER Upper 95% Limit ROWPER Sample Size Weighted Size

Marlboro Menthol 4.60 3.92 5.94 85 1621802

Marlboro (non-Menthol) 36.67 33.33 39.82 763 12924262

Salem (Menthol) 2.73 1.21 3.23 60 960995

Camel (non-Menthol) 5.75 5.24 6.51 115 2026065

Kool (Menthol) 2.81 2.43 3.26 90 992030

Newport (Menthol) 9.11 7.83 11.61 319 3211101

Menthol- All Other Brands 8.19 7.02 8.71 208 2887529

Non-Menthol- All Other brands 30.13 27.27 33.03 710 10620073

Source: National Health and Nutrition Examination Survey, 2003-2008. http://www.cdc.gov/nchs/nhanes.htm

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the stage/trajectory of cigarette smoking or those whodo not (usually) buy their cigarettes. Thus, adolescentsmokers are probably more prone to misreport the typeof cigarettes they smoke, including a menthol brand,than adult smokers do.As previously mentioned, collecting information on

the type of cigarettes smoked using the 8 or 12 digitUPC bar code information on the side of the cigarettepack may be seen as a solution to the problem of

obtaining accurate information on whether the brandsmoked by an adolescent is menthol or non-menthol.However, most of the national youth surveys (MTFS,NYTS, YRBS) that collect this type of information areconducted in a school-setting, a place where adolescentswho smoke may not bring their cigarettes and wheremost schools will not allow it. In household surveys (e.g., NSDUH), some of the novice or even experiencedsmokers may not want their parents/caregivers to know

Table 6 Prevalence for menthol by gender and age, NSDUH 2004-2008, by Year

YR Age GENDER Menthol RowPercent



SampleSize

WeightedSize

2004 18-25 Male Menthol Cigarettes 31.61 29.24 34.07 1184 2237546

Non-menthol cigs 68.39 65.93 70.76 2568 4841562

Female Menthol Cigarettes 37.14 35.48 38.83 1336 2102097

Non-menthol cigs 62.86 61.17 64.52 2298 3557619

26+ Male Menthol Cigarettes 24.91 23.04 26.88 676 5918660

Non-menthol cigs 75.09 73.12 76.96 2080 17838916


Non-menthol cigs 65.89 63.26 68.43 1700 13331830


Non-menthol cigs 68.55 66.7 70.34 2492 4790742


Non-menthol cigs 63.54 61.08 65.93 2147 3574756


Non-menthol cigs 75.96 73.45 78.31 2029 18501160


Non-menthol cigs 64.59 62.36 66.75 1743 13607506


Non-menthol cigs 66.55 64.31 68.71 2440 4575741


Non-menthol cigs 61.78 59.54 63.98 2007 3494550


Non-menthol cigs 73.28 70.95 75.49 1979 18129719


Non-menthol cigs 65.14 62.57 67.63 1728 13811082


Non-menthol cigs 64.1 61.86 66.28 2307 4229075


Non-menthol cigs 58.99 56.73 61.2 1857 3013481


Non-menthol cigs 72.82 70.2 75.3 2010 17868170


Non-menthol cigs 65.31 63.14 67.41 1733 13586371


Non-menthol cigs 61.9 59.53 64.21 2275 3991319


Non-menthol cigs 56.88 54.43 59.3 1816 2884040


Non-menthol cigs 71.95 69.18 74.55 1825 17370270


Non-menthol cigs 63.13 60.21 65.96 1665 13381077


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they smoke. Also, they may be less likely than an adultsmoker to have a pack of cigarettes with them. There isample evidence that a degree of self-report bias exists inreporting the use of mentholated cigarettes, especiallyamong adolescents. Assuming that this type of bias isfairly constant over time, the increase over time inmenthol cigarette use among adolescents and adults is areal one.

ConclusionThere is evidence that menthol cigarettes are dispropor-tionately smoked by U.S. adolescents, blacks/AfricanAmericans, adult females, those living in the Northeastof the United States, and those with lower familyincomes than their counterparts. It is likely that otherdisparities in menthol cigarette use exist that we havenot covered or have not been studied. Based on self-reports of menthol cigarette use, the use of mentholcigarettes among smokers have increased in recent yearsamong adolescents aged 12-17 years, young adults aged18-25 years, adults aged 26 years or older, white andHispanic men. No upward trend was observed for pre-dominantly menthol brands such as Newport™, Kool,™or Salem™, although this may be due, at least in part,due to smaller numbers of smokers who smoked thesespecific brands or sub-brands of cigarettes, whichresulted in less precise estimates.

AcknowledgementDisclaimerThe findings and conclusions in this manuscript are those of the authorsand do not necessarily represent the official position of the US Government,the US Department of Health and Human Services, or Centers for DiseaseControl and Prevention.This article has been published as part of Tobacco Induced Diseases Volume9 Supplement 1, 2011: Mentholated cigarettes and public health. Publicationof this supplement has been supported by the Center for TobaccoProducts, Food and Drug Administration. The full contents of thesupplement are available online at http://www.tobaccoinduceddiseases.com/supplements/9/S1

Author details1Mail Stop K-50, Office on Smoking and Health, National Center for ChronicDisease Prevention and Health Promotion, Centers for Disease Control andPrevention, 4770 Buford Highway, N.E., Atlanta, GA, USA. 2Research TriangleInstitute (RTI) International, Koger Center, Oxford Building, Suite 119, 2951Flowers Road South, Atlanta, GA, USA.

Authors’ contributionsRC was the lead scientist on the project and responsible for the intellectualconception and design of the study including the data analysis andinterpretation of the data. KA contributed to the conception of the study,conducted the data analysis, and help with the interpretation of the data.

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Source: National Surveys on Drug Use & Health, 2002-2008. http://oas.samhsa.gov/nhsda.htm

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Source: National Surveys on Drug Use & Health, 2002-2008. http://oas.samhsa.gov/nhsda.htm

Figure 14


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http://www.tobaccoinduceddiseases.com/supplements/9/S1

http://www.tobaccoinduceddiseases.com/supplements/9/S1

KA also helped draft and revise the final manuscript. Both authors haveapproved the final version of the manuscript for publication.

Competing interestsThe authors declare that they have no competing interests.

Published: 23 May 2011

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